Briefings on Accreditation and Quality

Briefings on Accreditation and Quality P5 P5 P8 Updated pharmacy regs CMS has updated pharmacy and nursing Conditions of Participations in response to concerns about compounding medications. Check out our chart to see what s changing. Discharge planning changes Substantial changes to discharge planning requirements are on the horizon. Read about CMS proposed changes to discharge planning regs and find out how to get ready. It s all about education The number of topics The Joint Commission and CMS require for staff education and training keeps growing. Find tips for staying on top of education and training requirements. Volume 26 Issue No. 2 FEBRUARY 2016 CMS tightens regulations around compounding medications Medications that are prepared outside the pharmacy will soon come under more intense scrutiny by state surveyors, based on recent CMS updates related to pharmacy services. On October 30, 2015, CMS announced revisions to the survey process and Interpretive Guidelines for the pharmaceutical services and nursing services Conditions of Participation (CoP). The changes: Update parts of the pharmaceutical services CoP to better align with accepted pharmacy standards of practice. The revised guidance addresses issues related to compounding (custom-preparing) medications, determining beyond-use dates, safe storage, and policies and procedures surrounding high-alert medications and minimizing drug errors. Clarify that hospital staff must follow accepted standards of practice when preparing compounded sterile preparations (CSP) outside the pharmacy. The revisions reflect current pharmacy standards in practice under U.S. Pharmacopeia (USP) 795 and 797, says Jeff Dandurand, PharmD, BCPS, lead pharmacy consultant for Compass Clinical Consulting and director of clinical consulting for Clinical Pharmacy Associates. However, while pharmacists will be familiar with these standards, nurses and other staff members who prepare medications outside the pharmacy may not. As a result, hospitals will need to educate nurses and review their practices for preparing medications outside the pharmacy to ensure compliance, Dandurand says. The changes also give CMS the ability to enforce that hospitals are following accepted pharmacy practices. By putting [compounding standards] into the CoP, whether it s in the Interpretive Guidelines or in the survey procedures section, it gives it more teeth so that the surveyors can actually cite hospitals for noncompliance, says Victoria Fennel, PhD, RN-BC, CPHQ, director of accreditation and clinical compliance for Compass Clinical Consulting. Compounding concerns The changes come in the wake of a 2012 meningitis outbreak caused by contaminated compounded medications

Briefings on Accreditation and Quality February 2016 prepared by the New England Compounding Center. The outbreak led to 64 deaths and sickened hundreds of people. Health organizations have also raised concerns over sterile compounding practices. An article published in the Institute for Safe Medication Practices January 15, 2015 newsletter asserted that the Institute has observed unsafe practices associated with sterile compounding in hospitals and that pharmacies have failed to learn from serious compounding errors at other facilities. After the meningitis outbreak, the Office of Inspector General (OIG) led an investigation into hospitals use of compounding pharmacies. In January 2015, the OIG issued a follow-up report on CMS and other accrediting organizations oversight of compounded pharmaceuticals used in hospitals. The report recommended that CMS ensure hospital surveyors are trained on nationally recognized standards for safe compounding practices. In response, CMS has revised its guidance in Appendix A of the State Operations Manual to include more information about compounding and medication administration, updating the following sections: The guidance for the Hospital Pharmaceutical Services CoP at 42 CFR 482.25 The Nursing Services CoP at 42 CFR 482.23 Along with these revisions, CMS also announced that it would provide targeted surveyor training related to compounding. What s changing? The revisions clarify several issues related to pharmacy standards, including: What constitutes compounding medications Requirements for personnel who prepare, store, or transport compounded medications Beyond-use dating for medications Fennel and Dandurand say they have observed confusion about what is considered compounding or even mixing medications among nurses. The revised guidelines use the USP definition of compounding, which is the preparation, mixing, assembling, altering, packaging and labeling of a drug, drug-delivery device, or device in accordance with a licensed practitioner s prescription, medication order or initiative based on the practitioner/patient/pharmacist/compounder relationship in the course of professional practice. This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIAL ADVISORY BOARD Jay Kumar Associate Product Manager jkumar@hcpro.com Follow Us Follow and chat with us about all things healthcare compliance, management, and reimbursement. @HCPro_Inc Emily Beaver Contributing Editor Sue Dill Calloway, RN, MSN, JD, CPHRM Chief Learning Officer The Emergency Medicine Patient Safety Foundation Columbus, Ohio Joseph L. Cappiello Chief Operating Officer Healthcare Facilities Accreditation Program Chicago, Illinois Sharon Chaput, RN, CSHA Brattleboro Retreat Brattleboro, Vermont Jean Clark, RHIA, CSHA Consultant Hollywood, North Carolina Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA Healthcare Consultant Trabuco Canyon, California Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHA Principal Consultant, Accreditation and Clinical Compliance Services University Healthsystem Consortium Chicago, Illinois Renee H. Martin, RN, JD, MSN Tsoules, Sweeney, Martin & Orr Exton, Pennsylvania Patrick Pianezza, MHA Manager of Patient Experience VEP Healthcare Walnut Creek, California Diane Rogier Former President NAHQ Glenview, Illinois Briefings on Accreditation and Quality (ISSN: 1941-5877 [print]; 1941-5885 [online]) is published monthly by HCPro, a division of BLR. Subscription rate: $429/year or $772/two years. Back issues are available at $30 each. Briefings on Accreditation and Quality, 100 Winners Circle, Suite 300, Brentwood, TN 37027. Copyright 2016 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978-750-8400. For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. 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February 2016 Briefings on Accreditation and Quality The revised guidelines state that all compounding of medications used or dispensed by hospitals must meet or exceed the standards in the USP compounding chapters, which are 795 and 797. USP 795 addresses non-sterile compounding practices, which are typically used for ointments or capsules, which are considered lower risk than CSPs. USP 797 outlines minimum standards that must be followed by all healthcare personnel responsible for preparing, storing, and transporting CSPs, which are generally administered to patients by injection or infusion and considered higher-risk products. The revised guidelines clarify that CSPs prepared for immediate use outside the pharmacy must involve mixing no more than three products in a container, in accordance with USP 797. The standards in USP 797 also address the physical layout of the location where medications are compounded, as well as precautions and quality assurance measures for preparing, transporting, and storing CSPs, based on the level of risk for microbial contamination. The goal of USP 797 is to prevent harm to patients as a result of contamination, variability in strength, or other potential risks associated with compounding. Dandurand says that while this information isn t new to pharmacists, he thinks the added references to USP 797 will enhance compliance and knowledge around the CoPs in the pharmacy community. I think where you ll see the most significant changes to compliance in the hospital would be the education of nursing staff and their process and procedure for compounding immediate-use drugs, he says. Labeling and beyond-use dating Other significant additions to the CoPs are related to labeling and determining beyond-use dates for medications. The revised guidelines specify that safe medication use requires proper packaging and labeling. Specifically, each floor stock drug container should be labeled with: The name and strength of the drug Lot and control number equivalent Expiration date Appropriate cautionary and accessory statements, as well as expiration date and beyond-use date, as applicable For unit-dose systems, each single package should be labeled with the same information as specified for floor stock containers. Individual drug containers for patients should be labeled with the patient s full name and quantity of drug dispensed. The revisions also add information about beyond-use dating, which identifies the date and time when a medication must no longer be used, stored, or transported. The beyond-use date takes into account factors that could lead to deterioration or microbial growth during or after the original packaging is opened, and can never be later than the expiration date. The revisions also reiterate that under USP 797 standards, the beyond-use date is 28 days for multidose medication vials with antimicrobial preservatives that have been opened or needle-punctured, unless otherwise specified by the manufacturer. Beyond-use dates must be determined conservatively and be based on manufacturer s instructions, when available, the revisions state. Also, hospitals must have policies and procedures for pharmacy staff to determine beyonduse dates when not available from the manufacturer, which must meet or exceed USP standards for beyonduse dating. The revisions clarify that unless a CSP is immediately and completely administered by the preparer (or its administration is witnessed by the preparer), the CSP must be labeled with: Patient identification information Names and amounts of all ingredients Name or initials of the preparer The exact hour beyond-use date Not clearly labeling medications is an issue that Fennel says she often sees in hospitals. For example, a nurse might open a vial and date it, but not specify whether the date is the open date, the expiration date, or the beyond-use date. When this happens, you have no choice but to throw that medication away. You cannot administer it to the next patient because you don t know whether or not that was the day it was drawn up or the day it actually expired, Fennel says. Also, when the beyond-use date is 28 days from the open dates, it s important to precisely calculate exactly 28 days later rather than estimating a date approximately a month later, she says. 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 3

Briefings on Accreditation and Quality February 2016 What to expect from surveyors As a result of the updates to the revisions, surveyors are likely to more closely examine medications that are prepared outside of the pharmacy. I think one of the things that nursing needs to be aware of is that they may be asked questions about what types of medications they have to prepare for patients, Fennel says. If nurses mention several types of medications they re preparing, that may lead to questions for the pharmacy department, she says. For years, CMS has admonished hospitals to limit the amount of compounding nurses perform outside the pharmacy, Fennel says. In the revised guidelines, CMS reinforces that CSPs should only be prepared by the pharmacy, except during emergencies or when a patient needs a CSP immediately and it s not feasible for the pharmacy to do the preparation. However, in hospitals without 24-hour pharmacies, nurses often compound medications, and their practices are likely to be scrutinized more under the revised CoPs. The revised survey process under the nursing CoPs asks surveyors to observe whether immediate-use CSPs prepared outside the pharmacy follow the standards specified in USP 797. Dandurand says surveyors will be looking to see if nurses who compound medications: Have appropriate equipment Follow appropriate processes for compounding Use aseptic technique Properly label and date medications, particularly in regard to beyond-use dating Surveyors will ask to observe medication passes, which allows them to track several items, including positive patient identification, aseptic technique, handwashing, and patient education, Fennel says. [Surveyors] will be observing the preparation of the medication, and they ll be doing it with a closer scrutiny, she notes. There have been so many different outbreaks of infections related to medications not being prepared correctly that they feel that it is an obligation to ensure that [compounding] is being done correctly outside of the pharmacy that all of the controls that are possible are being put into place so we can reduce the risk of transmitting an infection to a patient. Educating staff members Dandurand and Fennel say it s important for hospitals to educate nursing and other staff members responsible for preparing medications outside of the pharmacy to ensure they re in compliance with the pharmacy standards addressed in the CoPs. When it comes to providing education for nursing, the most effective resource is already in their own hospital, which is the pharmacy staff, Dandurand says. He recommends working with the pharmacy staff and the quality department to ensure nurses are educated about the standards and have the appropriate resources for compounding on the nursing unit. The American Society of Health-System Pharmacists also provides a comprehensive program for sterile and non-sterile compounding techniques. Hospitals can add training about pharmacy standards to orientation for staff members responsible for compounding medications outside of the pharmacy, as well as make the subject a competency for existing staff members, Fennel says. It s important to not only test staff members knowledge about the process, but to observe their process to ensure they re correctly compounding, labeling, and administering medications. H For more information Check out the following resources for more information about the revisions to CMS Conditions of Participation, as well as pharmacy standards and best practices: CMS Survey and Certification letter 16-01: Visit www.cms.gov and search for Survey and Cert Letter 16-01. The memo is dated October 30, 2015. OIG report on Medicare oversight of compounded pharmaceuticals: http://oig.hhs.gov/oei/reports/ oei-01-13-00400.pdf U.S. Pharmacopeial Convention: www.usp.org American Society of Health-System Pharmacists Sterile Compounding Resource Center: www. ashp.org/sterilecompounding Institute for Safe Medication Practices: www. ismp.org 4 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

February 2016 Briefings on Accreditation and Quality Where to find updates related to compounding and pharmacy standards State Operations Manual, Appendix A Section Subsection Subject A-0405 (revised) 482.23 (c) Standard on preparing and administering drugs A-0489 (revised) 482.25 Pharmaceutical services Condition of Participation A-0490 (new) 482.25 Standard-level tag for pharmaceutical services Condition for Coverage A-0491 (revised) 482.25 (a) Pharmacy management and administration standard A-0492 (revised) 482.25 Requirements for hospital pharmacy or drug storage area management and supervision 482.25 (a)(1) Requirements for hospital pharmacy services supervision and oversight A-0500 (revised) 482.25 (b) Delivery of services standard A-0501 (revised) 482.25 (b)(1) Requirements for oversight and governing laws for compounding, packaging, and dispensing drugs A-0502 (revised) 482.25 (b)(2)(i) Requirements for secure drug storage A-0505 (revised) 482.25 (b)(3) Requirements for managing outdated, mislabeled, or otherwise unusable drugs/biologicals A-0507 (revised) 482.25 (b)(5) Requirements for stopping delivery of drugs/biologicals without prescription or dosebased end times A-0510 (revised) 482.25 (b)(8) Requirements about the availability of critical drug information, such as interactions or side effects, for professional staff Source: www.cms.gov. Get ready for changes to CMS discharge planning requirements Healthcare providers could see significant changes to CMS requirements for discharge planning later this year. On November 3, 2015, CMS announced proposed revisions to the discharge planning Conditions of Participation (CoP) for hospitals, home health agencies, and critical access hospitals. The proposed changes would require hospitals to create discharge plans for all inpatients and certain types of outpatients, rather than simply identifying which patients should have discharge plans. The changes would also add more specific requirements about providers process for discharge planning as well as the information that must be included and considered in discharge plans. The proposed changes implement the discharge planning requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, which requires hospitals, critical access hospitals, and certain postacute care providers to use data on quality and resource use measures to help with discharge planning. CMS says a key piece of the proposed changes requires hospitals to take the goals and preferences of patients and their families into account during discharge planning. If this policy is adopted, individuals will be asked what s most important to them as they choose the next step in their care whether it s a nursing home or home care, CMS Acting Administrator Andy Slavitt said in a press release. The proposed changes will have some major impact on hospitals, says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCMSP, president of Patient Safety and Healthcare Consulting, Inc. If approved, the proposed changes will require hospitals to update their discharge planning policies, processes, and forms. That all takes a lot of time, Dill Calloway says. 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 5

Briefings on Accreditation and Quality February 2016 Reducing readmissions and the IMPACT Act The changes come as hospitals are under pressure to reduce readmissions thanks to the Hospital Readmissions Reduction Program, which cuts Medicare payments to hospitals with readmission rates above the national average for certain diagnoses. In the Background section of the proposed changes to the discharge planning CoPs, CMS cites research that estimates one-third of readmissions could be prevented with better transitions of care from the hospital to the community. CMS refined its discharge planning standards in 2004, in response to a growing recognition of the need to make discharge from the hospital to another care environment safer, and to reduce the rise in preventable and costly hospital readmissions. Later in 2014, the IMPACT Act required modifications to the CoPs and Interpretive Guidelines to mandate postacute care providers, hospitals, and critical access hospitals to consider quality, resource use, and other measures to improve discharge planning. In response to the IMPACT Act and efforts to reduce avoidable readmissions, CMS proposed changes to discharge planning CoPs. Patients and their caregivers frequently are not meaningfully involved in the discharge planning process and are unable to name their diagnoses; list their medications, their purpose, or the major side effects; cannot explain their follow-up plan of care; or articulate their treatment preferences and goals of care... This puts patients at risk for serious complications and increases their chances of being re-hospitalized, according to CMS introduction to the proposed CoP. What s new CMS proposed changes would make several updates to the discharge planning CoP for hospitals at 482.43, addressing: Hospital discharge planning processes Which patients require discharge plans Time frames for developing discharge plans and the information discharge plans must contain Discharge planning requirements for patients discharged to home or the community Discharge planning requirements for patients discharged to another healthcare facility Currently, hospitals are only required to identify patients for whom a discharge plan is necessary, but this does not necessarily lead to a discharge plan, CMS states in the introduction accompanying the proposed changes. Discharge planning varies from hospital to hospital, as some facilities use criteria to determine which patients require discharge plans, while others develop discharge plans for all inpatients. The proposed changes would require hospitals to develop discharge plans for: All inpatients Outpatients receiving observation services Outpatients undergoing surgery or same-day procedures that involve anesthesia or moderate sedation Emergency department patients identified in the hospital s discharge planning policies and procedures Any other category of patients specified by the hospital s discharge planning policies and procedures, approved by the hospital s governing board Timelines and written instructions The updates add time frames for when discharge planning and related tasks must occur. Under the proposed changes, hospitals must begin discharge planning within 24 hours of admission or registration, and complete it before the patient is discharged. If a patient s stay is less than 24 hours, hospitals would be required to complete the discharge planning process before the patient leaves the hospital. For patients who are discharged home, hospitals would need to provide a copy of discharge instructions and summary to the practitioner responsible for followup care, if known, within 48 hours. Pending test results would need to be provided to the practitioner within 24 hours of their availability. The proposed changes also specify the information hospitals must provide within discharge plans. For patients who will return home after discharge, hospitals must provide the patient and/or the patient s caregiver: Instructions on post-hospital care to be used at home, based on the patient s discharge plan Written information about warning signs that require immediate attention and information about who to contact if warning signs arise Information about prescriptions and over-the-counter medicines required after discharge 6 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

February 2016 Briefings on Accreditation and Quality Reconciliation of post-discharge and preadmission medications Written instructions, either on paper or in electronic format, about follow-up care, appointments, pending or planned diagnostic tests, and pertinent contact information, including any providers involved in follow-up care For patients who will be transferred to another healthcare facility, the proposed changes specify 21 items to be included in the information that hospitals must send to the receiving facility during the transfer. Giving patients data and choices The proposed changes to the discharge planning CoPs include several provisions focused on providing patients with quality data to make choices about their care after discharge, as well as using patient preferences to determine discharge plans. Hospitals would be required to help patients and their families select postacute care providers by using or sharing data about the quality and cost of home health agencies, skilled nursing facilities, inpatient rehab facilities, long-term care hospitals, and other providers. Patients and their families that are well informed of their choices of high-quality PAC providers, including providers of community services and supports, may reduce their chances of being re-hospitalized, according to the background section of CMS proposed changes. Hospitals would be expected to document the postacute care data used to help patients with discharge planning in the medical record. In the proposed changes to the discharge planning CoP, CMS advises providers to use data available through the Nursing Home Compare and Home Health Compare websites until the IMPACT Act finalizes its quality and resource use measures for postacute care. While hospitals are expected to gather data related to options for post-discharge care, CMS emphasizes that providers should use the information to increase patient participation in discharge planning, rather than make decisions for patients. The proposed changes also include a new requirement for discharge plans to address the patient s goals of care and treatment preferences. CMS would expect providers to discuss the patient s goals and preferences with the patient and his or her family, document those preferences in the medical record, and take them into account throughout the discharge planning process. Although healthcare providers should already be involving patients in these decisions, this doesn t always happen, Dill Calloway says. In the past sometimes we ve just said, You re going to do this and you re going to do that instead of asking the patient, she adds. What s next The public comment period for the proposed updates to the discharge planning CoPs was expected to close on January 4, 2016. After reviewing the comments, CMS will publish a discussion of the comments and eventually issue a final decision on the proposed rule. With more than 20 pages of proposed changes, it s likely that hospitals will have a good deal of work to do to prepare for them, Dill Calloway says. There s just a lot that hospitals have to do, she says. They re going to have to redo their discharge planning evaluation to include the requirements. To start getting ready for updates to the discharge planning requirements, she recommends that hospital staff members attend webinars or prepare their own presentations to educate staff members about the changes. For more information For more details about the revisions to discharge planning requirements for hospitals, critical access hospitals, and home health agencies, visit: http://federalregister.gov/a/2015-27840 For more information about the IMPACT Act: Go to www.cms.gov Select the Medicare tab Scroll down to the Quality Initiatives/Patient Assessment Instruments section and select Post-Acute Care Quality Initiatives In the left navigation, select IMPACT Act of 2014 Data Standardization & Cross Setting Measures 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 7

Briefings on Accreditation and Quality February 2016 Dill Calloway suggests that hospitals convene a committee responsible for updating discharge planning processes to comply with the new requirements, including physicians and midlevel providers, social workers, and discharge planners. The committee should identify actions the hospital needs to take to comply with changes, such as: Updating discharge planning policies and procedures Rewriting discharge planning evaluation tools Revising transfer forms She recommends appointing a leader for the discharge planning committee, such as the chief nursing officer or director of social work, to ensure committee members accomplish all required tasks on time. H How to comply with the updated staff education and training requirements from Joint Commission, CMS Editor s note: The following article was written by healthcare consultants Marlene Strader, PhD, RN, and BOAQ advisor Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA. Both are former surveyors for The Joint Commission. It has now been 20 years since The Joint Commission and CMS have required training and education for staff. Each year there are more topics for hospitals to include in their training and education programs. From approximately 27 topics appearing in various standards in 2010, the list now is up to more than 40 topics and growing (see table on pp. 10 12). One topic was dropped off the list by both The Joint Commission and CMS: the requirement regarding education and training for appropriate staff on blood transfusions and IV medications. The Human Resources (HR) chapter of the Comprehensive Accreditation Manual for Hospitals (CAMH) is not the only chapter where education and training is addressed. There are multiple other chapters identifying education, including Environment of Care, Information Management, Infection Control, Medical, Rights and Responsibilities, National Patient Safety Goals, Leadership, and Provision of Care; education and training is also addressed in Sentinel Event Alerts (see table). To locate the primary resource standards and element of performance requirements also takes time. In addition, there is a new requirement that has just appeared in the latest proposed prepublication standards: Standard MM.09.01.01, which relates to the new antimicrobial stewardship program. It requires education of staff and LIPs involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and antimicrobial stewardship practices. This education should take place upon hire and annually thereafter. CMS also has been including more topics for education, including some that carry heavy weight and could create an immediate jeopardy situation. For example, in some areas of the country, hospitals have received an immediate jeopardy finding because they failed to show adequate training and education for security guards who assist staff in holding patients in the emergency department who are violent and aggressive when restraints are applied (see table). Another immediate jeopardy finding is related to glucometer testing. Nurses and others who perform the test are finding themselves out of compliance with infection control practices: specifically, the multiple wipe-downs of the glucometer and multiple uses of hand hygiene, and glove changes between steps. CMS also has a requirement for training that sometimes gets overlooked namely, first aid techniques and certification in use of cardiopulmonary resuscitation for all staff who are involved in restraints, including security guards who participate in holds (see table). While the list of Joint Commission topics is somewhat daunting, there have been other additions to the 8 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

February 2016 Briefings on Accreditation and Quality requirements regarding education and training for specific staff. The HR chapter does not address physicians, LIPs, or allied health practitioners, such as NPs and PAs; however, the expectation is that these individuals are included in many of the requirements. Frequency of education and training There are specific time frames for education and training set out by The Joint Commission and CMS. For topics that do not specify education/training at hire and annually, the hospital can determine frequency; many hospitals are adopting a biennial time frame, if it meets applicable law and regulation. Specific requirements for education and training to occur at hire and annually are as follows: Training and education on radiation dose reduction techniques annually and ongoing Safe practices in MRI environment annually and ongoing Prevention of multidrug-resistant organisms (MDRO) at hire and annually Prevention of central line infections at hire and annually Prevention of surgical site infections at hire and annually Proposed education about antimicrobial resistance and antimicrobial stewardship practices at hire and annually Restraint education, training, and competency at hire and implied annually Glucometer training at hire Waived testing at hire and annually Required personnel LIPs, NPs, and PAs should receive education regarding prevention of MDROs, central line infections, and surgical site infections at hire and annually. While education about MDROs applies to most providers in the hospital and off-site services, the hospital can define which category of staff requires education about central line and surgical site infections. Certainly, providers who are not involved in central line insertion (or care of these patients) and surgical procedures would not be required to have this education. The requirement for restraint education for physicians, other LIPs, NPs, and PAs authorized to order restraint or seclusion by hospital policy, in accordance with state law, is to have at minimum a working knowledge of hospital policy regarding the use of restraint and seclusion. It is important to make sure NPs and PAs are included when personnel files are reviewed. Often contract and agency personnel are a forgotten group. The hospital must define the expectations for these individuals and how they will comply with the requirements. Contractors and agencies may provide education and training that has been approved by the hospital. One important thing to remember: These personnel files will almost assuredly be requested during the HR interview. Hospitals are expected to educate radiology staff who are monitored for radiation exposure about the appropriate use of the monitoring meters or badges (or through use of a personal radiation monitoring device, which employs modern technology for the same measurement purpose). These individuals must be educated on the importance of tracking their radiation exposure over various time frames, such as the most recent month and year, as well as their cumulative exposure through work. They also must be educated about the appropriate storage of the meters and/or badges as well as procedures to follow if exposure exceeds cumulative dosage parameters specified per hospital policy. The expectation is for proactive monitoring of staff cumulative dosage and taking appropriate steps if an individual staff member s cumulative dosage level exceeds parameters. Most hospitals have a robust educational program for their radiology staff; however, the new requirement is to make sure this is documented annually and ongoing in personnel files. It is also important to identify who is required to obtain the necessary education this will take some thought-provoking decision-making. For example, are respiratory therapists required to have education about organ donation? Some hospitals put everyone in the education basket as it seems easier to achieve compliance by doing so, but this is a burden for those individuals who have neither responsibility nor any relationship to the topic, and it can be costly for the hospital. It would be appropriate to perform a risk assessment of an individual s need for education and training specific to his or her job description. 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 9

Briefings on Accreditation and Quality February 2016 Reducing the burden It can be overwhelming for hospitals to take into account the Joint Commission and CMS requirements, figuring out how to include all of them along with their own areas of mandatory education. Computer-based training modules have been developed by many hospitals. This may be the simplest method to provide education and training, but not all of it should be conducted in this manner. However, if a computer-based format meets most of a hospital s needs, it is strongly suggested that some prioritization of topics occur. In other words, what is the most/ least important? Does a topic contribute to improving patient care or provide compliance with requirements that are difficult to consistently maintain (e.g., pain management education)? Patients still complain their pain needs are not met; thus, this particular topic may be seen as an ongoing priority, which might suggest annual rather than biennial training. In addition, it also seems that many of the topics could be reduced by including them under one major heading. For example, infection control could include glucometer training, education about prevention of MDROs, CLABSIs, and SSIs, as well as influenza vaccine. Education about National Patient Safety Goals could also include a majority of topics required. If hospitals should decide to reduce the number by including these topics under one section, it is important to identify where surveyors can locate the required topics. Some hospitals highlight or tab the areas where the relevant information is located. While the list keeps growing, there are proposed changes by The Joint Commission. It will be important to review the accreditor s reduction in required EPs that will be performed in stages beginning in July 2016. There may be deletions in the education and training chapters. H Reference Comprehensive Accreditation Manual for Hospitals e-dition, January 2016. 2016 hospital education and training requirements: Joint Commission, CMS # Topic 1. Employees reporting safety concerns (to hospital management or Joint Commission without fear of retaliation) 2. Fire safety, security, haz mat, etc., MRI risk reduction, emergency management Standard CoP APR 09.02.01 EC.03.01.01 482.41(a) 482.41(b)(7) Orientation and ongoing education Orientation Orientation Required personnel * and LIPs, LIPs, PAs, NPs 3. Training for interpreters HR.01.02.01 4. Pain assessment and management HR.01.04.01 Orientation and ongoing education and LIPs, PAs, NPs MS.03.01.03 5. Cultural diversity HR.01.04.01 Orientation 6. Orientation HR.01.04.01 Organizational and departmental All employees orientation, 30-day grace 7. Patient rights and ethics HR.01.04.01 Orientation RI.01.01.01 8. Advanced directives 482.23(b)(3) Ongoing Appropriate staff 9. Infection control HR.01.04.01 482.42 Orientation 10. Glucometer training 482.42 who perform glucometer testing 10 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

February 2016 Briefings on Accreditation and Quality 2016 hospital education and training requirements: Joint Commission, CMS (cont.) # Topic Standard CoP Orientation and ongoing education Required personnel * 11. Forensic restraint, interaction with patients HR.01.04.01 Orientation Law enforcement, security personnel 12. Team training and communication HR.01.05.03 13. How to report unanticipated adverse events HR.01.05.03 14. Population (age specific) education and competency HR.01.05.03 15. Fall reduction program HR.01.05.03 16. Early warning signs change in condition HR.01.05.03 17. Training and education on radiation dose reduction techniques, addressed in Image Gently & Image Wisely, and safe procedures for operation of types of CT equipment used, agency and contract staff and LIPs as necessary HR.01.05.03 Annual and ongoing Radiologic technologists who perform CT examinations 18. Safe MRI practices in MRI environment HR.01.05.03 Annual and ongoing MRI technologists who perform MRIs 19. Safe practices in radiology 482.26(b) Ongoing Radiology staff 20. Orientation, competency, training HCWs who are processing devices, medical equipment and supplies IC.02.02.01 Orientation as necessary for new employees 21. Health screening PPD IC.02.03.01 Required annual fit testing All staff as applicable: highlevel disinfection, OR, ultrasound GI, central sterile, etc., agency and contract staff 22. Influenza vaccine IC.02.04.01 and LIPs 23. Alternate procedures to follow when electronic IM.01.01.03 and LIPs systems are not available 24. Mission, vision, goals LD.02.01.01 Orientation 25. Safety and quality for all individuals, including code of conduct LD.03.01.01 26. PI and change management QAPI 27. Proposed education about antimicrobial resistance and antimicrobial stewardship practices LD.03.05.01 482.21 28. Anticoagulation therapy NSPG 3 03.05.01 29. Purpose and proper operation of alarm systems for which they are responsible 01-2016 MM.09.01.01 At hire and annually and LIPs involved in antimicrobial ordering, dispensing, administration, and monitoring NPSG 6 06.01.01 30. HAIs, MDROs, and prevention strategies NSPG 7 07.03.01 At hire and annually, based on risk assessment Prescribers, staff and LIPs, PAs, and NPs 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 11

Briefings on Accreditation and Quality February 2016 2016 hospital education and training requirements: Joint Commission, CMS (cont.) # Topic Standard CoP 31. CLABSI NSPG 7 07.04.01 32. SSI NSPG 7 07.05.01 Orientation and ongoing education At hire and annually based on risk assessment At hire and annually based on risk assessment 33. Impairment recognition of LIPs MS.11.01.01 34. Abuse and neglect & exploitation PC.01.02.09 482.13(c)(3) 35. CPR/BLS/ACLS as required by hospital PC.02.01.11 If required by job description, ongoing certification as per certification requirements 36. Needs of dying patient PC.02.02.13 37. Moderate, deep, sedation, anesthesia PC.03.01.01 Ongoing demonstration of competency 38. Restraint patient care PC.03.03.07 non-deemed PC.03.05.17 deemed 482.13f Orientation standard requires competency annually implied 39. Restraint education 482.13(e)(11) Working knowledge of hospital policy regarding use of restraint/ seclusion 40. Restraint training CMS 482.13(f) (2)(vii) 41. Training (discretion & sensitivity to circumstances, beliefs, and desires of families of potential donors) TS.01.01.01 482.45(a)(5) Use of first aid techniques & certification in use of cardiopulmonary resuscitation, including required periodic recertification 42. Waived testing evidence of two tests WT.03.01.01 Education & training At hire and annually 43. Training that requires the use of an instrument training on use and maintenance 06-01-2015 44. Education on radiation dosing and training on specific model of equipment used 45. Inspection safety and prevention of medication vial misuse 46. Safe handling & prep of authorized meds Equipment, devices, special procedures and/or techniques required for medication administration Required personnel * Healthcare workers, as appropriate Healthcare workers, as appropriate LIPs and other relevant staff, PAs, NPs Hospital defines staff as required by applicable law/ regulation Nurses, PAs, NPs, LIPs who administer medications used for conscious sedation, agency and contract staff LIPs about restraint policy, PAs, NPs LIPs, PAs, designated house staff All staff who are involved in restraint, including security guards who participate in holds, physicians if instrument testing involved, credentialing, agency/contract staff WT.03.01.01, physicians Sentinel Event Alert 47 Sentinel Event Alert 52 482.23(c)(2) 47. Use of dose packaging system 482.25(b)(1) All applicable staff and LIPs who administer medication, LIPs, PAs, NPs Pharmacists, nurses, others as determined by healthcare organization (HCO) Pharmacists, nurses, others as determined by HCO *, as appropriate to role and responsibilities. All people who provide care, treatment, or services, volunteers and students, not LIPs. Source: Marlene Strader, PhD, RN, and Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA. Reprinted with permission. 12 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.